Determining Capacity

A 74 year old female with a GI bleed is refusing treatment, stating that she just wants to go home rather than being transfused for her hemoglobin is 5. You attempt to convince her to stay but she steadfastly says that she just wants to leave. She mentions she has to feed her dog and she wants to sleep in her own bed. What do you do next?

Calling psychiatry to determine capacity to make medical decisions seems like our default answer in the ED but emergency medicine physicians are actually capable of determining themselves if a patient has decision making capacity. Any physician responsible for caring for a patient can determine if a patient possesses capacity, and research comparing psychiatrists’ judgments to those of other physicians shows that they are no better at assessing capacity in practice.

To determine if a patient has decisional capacity, a physician must assess 4 specific capabilities:

  • Ability to understand information relevant to treatment decisions
  • Ability to appreciate the significance of the information
  • Ability to weigh treatment options and demonstrate reasoning
  • Ability to express a choice

A formal, structured assessment tool can be used to evaluate capacity. Two such tools are the Aid to Capacity Evaluation (ACE) and the MacArthur Competence Assessment Tool (MacCAT); the ACE is shorter and more clinically oriented. Both use standardized questions and scoring systems to achieve a more objective assessment of capacity although the abilities assessed are the same as above and still require interpretation by the evaluator.

Finally, it’s important to remember that Western culture both legally and ethically values patient autonomy and that any restriction requires a clear and convincing assessment that a patient’s decision regarding care will result in unintended, irreparable harm.

Thanks to Dr. Andrus for serving as the inspiration for this post!

Sessums LL, Zembrzuska H, Jackson JL. Does This Patient Have Medical Decision-Making Capacity? JAMA. 2011;306(4):420-427.
Markson LJ, Kern DC, Annas GJ, Glantz LH. Physician assessment of patient competence. J Am Geriatr Soc. 1994;42:1074–80.

043 | Sensory Innervation of the face Part 03 | Infraorbital Nerve

We’re back for another series – this time focussing on the sensory innervation of the face through the lens of dental anaesthesia.

This is adapted from a take I gave in EuSEM 2016 in Vienna. This is part 3

The most important links you need are:

The AFEM podcast will always be free but feel free to donate to help cover hosting and the cost of web hosting and producing new episodes

Donate via PayPal

iTunes | Generic RSS

The post 043 | Sensory Innervation of the face Part 03 | Infraorbital Nerve appeared first on Emergency Medicine Ireland.

New MRI Probe Highlights Fibrogenesis to Help Track Scar Formation Noninvasively

Tissue injuries often result in fibrogenesis, a process involving the development of an extracellular matrix that results in scars. While it can be viewed on the exterior of the body, currently there are no noninvasive methods to track the progress of fibrogenesis within the body’s interior. A team of researchers at Harvard Medical School have now developed a chemical probe that can be used to spot and quantify the amount of fibrogenesis using MRI scanners.

The probe is a gadolinium chelate (GdOA) which binds to allysine, an amino acid that’s present where collagen is creating connections. It concentrates at particularly high quantities where a great deal of fibrogenesis takes place, but doesn’t when a disease has stabilized. The gadolinium has an oxyamine functional group that binds to allysine, and because gadolinium is well visible under MRI, it highlights the locations of fibrogenesis.

In addition to clinical applications, this new probe will help to study diseases and injuries that involve fibrogenesis, potentially leading to new therapies and preventive strategies.

Study in journal Angewandte Chemie: Molecular Magnetic Resonance Imaging of Lung Fibrogenesis with an Oxyamine-Based Probe…

Via: Wiley…